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    <td align="center" >
  <h6><font size="2">CỘNG HOÀ XÃ HỘI CHỦ NGHĨA VIỆT NAM </font></h6>             
  <span style="font-family: Arial; mso-font-kerning: 14.0pt"><font size="2">Độc lập-Tự             
  do -Hạnh phúc</font> </span>           
    </td>
  </tr>
</table>

<p class=MsoNormal align=center style='text-align:center;word-spacing:0in'><span
style='font-family: Arial; mso-font-kerning: 14.0pt'><font size="2">***************</font></span></p>

<p class="MsoNormal" align="center" style="margin:0in;margin-bottom:.0001pt;
text-align:center"><b><span style="font-family: Arial, Helvetica, sans-serif"><font size="2">CẤP GIẤY CHỨNG NHẬN QUYỀN SỬ DỤNG ĐẤT <br>
CHO HỘ GIA ĐÌNH, CÁ NHÂN ĐANG SỬ DỤNG ĐẤT TẠI ĐỊA PHƯƠNG
</font></span></b></p>
    

<p class=MsoNormal style='word-spacing:0in' align="center">&nbsp;</p>  

<p class="MsoNormal" style="word-spacing: 0in" align="center"><b><i><u><span style="font-size:10.0pt;mso-bidi-font-size:
12.0pt;font-family:Arial, Helvetica, sans-serif">Kính gửi</span></u></i></b><span style="font-size:  
10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial, Helvetica, sans-serif">: <b>UBND xã (thị   
trấn)…#land_province#………………………………………………..<o:p>
</o:p>  
</b></span></p>
<table width="100%" border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable">
  <tr>
    <td>
     <span class="MsoNormal" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif">I   
      - PHẦN KÊ KHAI CỦA NGƯỜI SỬ DỤNG ĐẤT
      </span></td>
  </tr>
  <tr>
    <td valign="top">
      <p class="MsoNormal" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif">1   
      - Người sử dụng đất</p>
      <p class="MsoNormal" style="font-size:10pt;font-family:Arial, Helvetica, sans-serif">1.1.   
      Tên người sử dụng đất: <i>(Đối với cá nhân)</i>
      <br>Họ và tên:&nbsp;&nbsp;&nbsp; #USER_NAME#&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      Sinh năm:&nbsp;&nbsp;&nbsp; #USER_BIRTHDAY#&nbsp;&nbsp;&nbsp;&nbsp;   
      .<br>
      CMND số: #USER_CARD_ID# do công an   
      tỉnh (thành phố): #USER_CARD_PLACE#   
      cấp ngày #USER_CARD_DATE#
      <br>
      <br>
      1.2   
      Tên người sử dụng đất: <i>(Đối với hộ gia đình)
      </i>  
      <br>
      Họ   
      và tên v&#7907;/chồng: #HUSBAND_NAME# &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      Sinh năm: #HUSBAND_BIRTHDAY#<br>
      CMND   
      số: #HUSBAND_CARD_ID# do công an   
      tỉnh (thành phố): #HUSBAND_CARD_PLACE# cấp ngày: #HUSBAND_CARD_DATE#<br>
      <br>
	  Họ và tên vợ/chồng: #WIFE_NAME# &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Sinh năm: #WIFE_BIRTHDAY#&nbsp;&nbsp; <br>
	  CMND số: #WIFE_CARD_ID#&nbsp; do công an tỉnh (thành phố): #WIFE_CARD_PLACE#&nbsp;&nbsp;   
      cấp ngày: #WIFE_CARD_DATE#
      <br>
	Sổ hộ khẩu gia đình số: #so_ho_khau# cấp ngày: #ngay_cap_ho_khau#<br>
	<br>
1.3   
      Địa chỉ thường trú #USER_RESIDENT_ADDRESS#&nbsp;</td>
  </tr>
  <tr>
    <td width="753" valign="top">
       <p class="MsoNormal" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif">2   
      - Thửa đất xin cấp giấy chứng nhận quyền sử dụng đất</p>
      <p class="MsoNormal" style="font-size:10pt;font-family:Arial, Helvetica, sans-serif">
	  2.1.Thửa đất số: #PIECE_OF_LAND_ID#..;  <br>
      2.2. Tờ bản đồ số: #MAPPING_ID#<br>
		2.3.   
      Địa chỉ tại: #LAND_ADDRESS#.<br>
2.4.   
      Diện tích: #PIECE_OF_LAND_AREA#  .m<sup>2</sup>;   
      <br>
Hình thức sử dụng:<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;+ Sử dụng riêng: #PRIVATE_USE# .m<sup>2</sup><br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;+ Sử dụng chung: #PUBLIC_USE# .m<sup>2</sup>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<br>
2.5.   
      Mục đích sử dụng đất: #use_purpose#<br>
2.6.   
      Thời hạn sử dụng đất: #USE_TIME_LIMIT#<br>
2.7.   
      Nguồn gốc sử dụng đất: (Ghi rõ được cấp năm nào, do   
      cấp nào cấp hay đất của ông cha)<br> 
      #LAND_SOURCE#</p>    </td>
  </tr>
  <tr>
    <td valign="top">
      <p class="MsoNormal" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif">3 – Tài sản gắn liền với đất:</p>
      <p class="MsoNormal" style="font-size:10pt;font-family:Arial, Helvetica, sans-serif">3.1.
Loại nhà hoặc công trình xây dựng:&nbsp;&nbsp; #TRANFER_HOUSE_ADDRESS#.<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Diện tích xây dựng:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #BUILDING_AREA#.<br>
3.2. Cây rừng, cây lâu năm: #LAND_NOTE#<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;a) Loại cây:  #land_note_tree_type#.<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;b) Diện tích có cây:   #land_note_tree_area#</p>      </td>
  </tr>
  <tr style="mso-yfti-lastrow:yes">
    <td valign="top">
       <p class="MsoNormal" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif">4   
      - Những giấy tờ nộp theo đơn này gồm:
      </p>
       <p class="MsoNormal" style="font-size:10pt;font-family:Arial, Helvetica, sans-serif">#include_document#<br>
………..………………………………………………………………………………………………</p>    </td>
  </tr>
</table>
<p class="MsoNormal" style="font-size:10.0pt;mso-bidi-font-size:12.0pt;
font-family:Arial, Helvetica, sans-serif">Tôi xin cam đoan nội dung kê khai trên là đúng.</p> 
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  
      <i>Vũng Tàu , #RECEIVE_DATE#</i><br>
      <br>
      <br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<b>Người viết đơn
</b><br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(Ký và ghi rõ họ tên)</p> 

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<table class="MsoNormalTable" border="1" cellspacing="0" cellpadding="0" style="border-collapse: collapse; mso-table-layout-alt: fixed; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; border-style: none; border-width: medium" width="564" height="765">
  <tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:41.8pt">
    <td width="548" valign="top" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif" height="29">II 
      - PHẦN XÁC NHẬN CỦA UỶ BAN NHÂN DÂN XÃ, PHƯỜNG, THỊ 
      TRẤN ĐỐI VỚI HỘ GIA ĐÌNH, CÁ NHÂN</td>
  </tr>
  <tr style="mso-yfti-irow:1;height:247pt">
    <td width="548" valign="top" style="font-size:10pt;font-family:Arial, Helvetica, sans-serif">- 
      Nguồn gốc và thời điểm sử dụng đất: (Ghi rõ được 
      cấp năm nào, do cấp nào cấp hay đất của ông cha)<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
- Tình trạng tranh chấp, khiếu nại về đất đai:…………………………………………………..<br>
………..………………………………………………………………………………………………<br>
- Sự phù hợp với quy hoạch sử dụng đất: ………………………………………….…………..<br>
………..………………………………………………………………………………………………<br>
<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Ngày……..tháng……năm 
      200…. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
       Ngày……..tháng……năm 200…. <br>
       &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
       &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<b> Cán bộ địa chính   &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;TM. 
      Uỷ ban nhân dân xã (Thị trấn) </b>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      (Ký và ghi rõ họ tên)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      <b><i>Chủ tịch</i></b></td>
  </tr>
  <tr style="mso-yfti-irow:2;height:20.2pt">
    <td width="548" valign="middle" style="font-size:10pt; font-weight:bold;font-family:Arial, Helvetica, sans-serif" height="29">
      III 
      - KẾT QUẢ THẨM TRA CỦA PHÒNG TÀI NGUYÊN VÀ MÔI TRƯỜNG
    </td>
  </tr>
  <tr style="mso-yfti-irow:3;mso-yfti-lastrow:yes">
    <td width="548" valign="top" style="font-size:10pt;font-family:Arial, Helvetica, sans-serif" height="343">
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
………..………………………………………………………………………………………………<br>
      <br>
      &nbsp;&nbsp;&nbsp;&nbsp;Ngày……..tháng……năm 
      200….
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      Ngày……..tháng……năm 200….<br>      
      &nbsp; 
      &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<b>&nbsp; 
     Người thẩm tra hồ sơ&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
      Phòng 
     Tài nguyên và Môi trường</b>     <br>     
     &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(Ký và ghi rõ họ tên)</td>
  </tr>
</table>

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